What are the guidelines for managing fibromyalgia?

Fibromyalgia Management Guidelines

Initial Treatment Approach

Begin immediately with aerobic and strengthening exercise as the primary intervention, which has the strongest evidence (Level Ia, Grade A) for improving pain, function, and quality of life in fibromyalgia. 1

Non-Pharmacological Management (First-Line)

Exercise is the cornerstone of fibromyalgia treatment:

• Start low-impact aerobic exercise (walking, swimming, cycling) at 20-30 minutes, 2-3 times weekly, gradually increasing to 30-60 minutes, 5 days weekly 1
• Add progressive resistance training 2-3 times weekly 1
• Heated pool therapy or hydrotherapy provides additional benefit and may improve exercise tolerance (Level IIa, Grade B) 2, 1
• Exercise should be individually tailored and gradually increased based on tolerance to avoid symptom flare-ups 2

Additional evidence-based non-pharmacological therapies:

• Cognitive behavioral therapy (CBT) is recommended for patients with depression, anxiety, or maladaptive coping strategies (Level Ia, Grade A) 2, 1
• Acupuncture is recommended for pain reduction (Level Ia, Grade A) 1
• Meditative movement therapies including tai chi, yoga, or qigong are recommended (Level Ia, Grade A) 2, 1
• Mindfulness-based stress reduction programs are recommended (Level Ia, Grade A) 2, 1
• Multicomponent therapy combining exercise, CBT, and medication may provide greater benefit than any single intervention 2, 1

Pharmacological Management (Second-Line)

Add pharmacological therapy only after initiating non-pharmacological interventions, or concurrently if symptoms are severe. 2, 1

First-line medication options (all Level Ia, Grade A):

• Amitriptyline: Start 10-25 mg at bedtime for patients with prominent sleep disturbance and pain; titrate by 10-25 mg weekly to 50-75 mg as tolerated 2, 1
• Duloxetine: Start 30 mg daily for 1 week, then increase to 60 mg daily for patients with pain plus depression or anxiety 2, 1
• Pregabalin: Start 75 mg twice daily (150 mg/day), titrate to 150 mg twice daily (300 mg/day) within 1 week for patients with predominant pain without mood symptoms; may increase to 225 mg twice daily (450 mg/day) if insufficient benefit at 300 mg/day 2, 1, 3
• Milnacipran: Target dose 100-200 mg/day in divided doses, with dose escalation starting at lower doses and titrating up over approximately 1 week 2, 4

Second-line medication option:

• Tramadol: Consider for pain management (Level Ib, Grade A) when first-line medications are ineffective 2, 1

Treatment Algorithm

1. Week 0: Begin patient education about fibromyalgia as a chronic condition with central sensitization; initiate low-impact aerobic exercise program 2, 1

2. Week 4-6: If insufficient response, add heated pool therapy/hydrotherapy, CBT (if mood symptoms present), or acupuncture 2, 1

3. Week 4-8: If still insufficient response, add first-line pharmacological therapy based on symptom profile:

   • Sleep disturbance predominant → Amitriptyline 1
   • Depression/anxiety present → Duloxetine 1
   • Pain predominant without mood symptoms → Pregabalin 1

4. Week 12-16: Evaluate treatment response using pain scores (0-10 scale), functional status, and patient global impression of change 1

   • If partial response: Consider adding another first-line medication from a different class 2
   • If no response: Switch to alternative first-line medication 2

5. Ongoing: Reassess every 4-8 weeks; expect 30-50% pain reduction rather than complete resolution 1

Critical Medications to Avoid

• Corticosteroids have no role in fibromyalgia treatment (not an inflammatory condition) 2, 1
• Strong opioids (morphine, oxycodone, hydrocodone) are not recommended as they lack demonstrated benefit and carry significant risks 2, 1
• NSAIDs (ibuprofen, naproxen) have limited to no benefit as monotherapy since fibromyalgia is not an inflammatory condition 1

Important Clinical Considerations

• Most treatments show modest effect sizes; set realistic expectations with patients for 30-50% pain reduction rather than complete resolution 1
• Dropout rates due to side effects with SNRIs (duloxetine, milnacipran) are approximately double compared to placebo, though serious adverse events are not increased 2
• Pregabalin doses above 450 mg/day are not recommended due to dose-dependent adverse reactions without additional benefit 2, 3
• Long-term management requires ongoing exercise maintenance and periodic reassessment of medication need 1
• Regular reassessment every 4-8 weeks is essential to evaluate treatment efficacy and adjust the approach as needed 2, 1